The blog of Ashish Jha — physician, health policy researcher, and advocate for the notion that an ounce of data is worth a thousand pounds of opinion.

Monthly Archives: August 2013

On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder. I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.

As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.

The Emergency Room:

We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.

It started off well enough – a triage nurse saw me walking in holding my arm, in distress. She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life. I was then shuttled to registration, where I was asked to repeat all the same information. It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question. Initially, the same ones: name, address, phone #, etc. Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.

I told her I was in excruciating pain and needed help. A few more questions, she said. She needed the complete registration.

I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster. The x-ray technologist avoided eye contact. It was hard — I was right outside her room. Finally, I asked a passerby if she could help. Caught by surprise (I must have sounded human), she stopped. She looked at me. She then went into the x-ray suite. A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful. He told me the ER was pretty quiet and he would get me in right away.

One of the ways we measure quality of emergency department care is to examine the proportion of patients with a fracture who receive pain medications within 60 minutes. While I don’t know who came up with 60 minutes, it wasn’t anyone with first-hand experience sitting in a waiting room in excruciating pain. Even though I did not have a fracture, my injury was comparable – and I was getting pretty close to 60 minutes when I was wheeled from the x-ray suite back out to the waiting room. I hadn’t been assigned a room, I was told. Still no pain medicine. How much longer before I could be seen, I asked? No one seemed to know. When I was eventually wheeled back to the treatment area, I was told I had to wait for a physician before I could get pain medication. How soon, I asked? No one knew. The ER doc actually came pretty quickly — he ordered some morphine and things became better. He was very good at what he did – he manipulated my shoulder and while it was insanely painful, I knew it had to be done. My shoulder popped back in quickly with amazing relief.

The Lessons Learned:

The rest of the time in the ER was uneventful. As I sat on my gurney awaiting the results of the repeat x-ray, I sent out a Tweet. I described the experience as wonderful people, awful system.

1) People who work in hospitals can be wonderful: One could ask if the people there really had been so wonderful. Why didn’t the triage nurse take me back right away and skip parts of registration (or at least express sympathy for my pain)? Why couldn’t the registration person wait for the minute details? Why did all those people look away when they heard me groan? I can’t imagine walking by somebody groaning in pain and ignoring them. Except I probably have. In the hospital. And why do we do that? Why do we leave our humanity at the door when we arrive to work? I assume we just get desensitized to suffering.

What was remarkable was that there were people who were able to break out of that trap. When I was able to engage someone as a person, they responded. The woman who stopped when I asked for help. The second x-ray technologist who expressed sympathy for my pain. The ER physician who took care of my shoulder quickly when he realized the severity of my pain. It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering. It’s clearly possible and several people showed it at Falmouth. And yet, too few healthcare organizations appear to have those kinds of leaders.

2) We have a lousy system. There were so many reminders in my short visit to the ER. Asking someone in excruciating pain to repeat demographic information and wait for their insurance information to come up on the computer? Even when I pleaded with her, she blew it off, reassuring me insurance information was important. Because that’s how we do business in healthcare. Making sure I was insured was much more important than making sure I was treated quickly.

When telling this story to colleagues, one person even defended it. Asking people to wait in pain is fine, she said, because registration information is valuable. Really? That’s the tradeoff? We can’t design a system where some of the information is obtained when the pain is better? There was no way to take my credit card as collateral and let me go on my way? Can we really not design a better flow so that patients with severe pain get relief without waiting needlessly? There were so many little opportunities to make my process faster, but it was clear that there was no reason for the hospital to invest in those changes. No one holds them accountable. In most industries, the payer holds the provider of poor services accountable. Not in healthcare.

Not an extraordinary story:

The biggest lesson for me was that this was not an extraordinary story at all. When I told my story to colleagues the next day, no one was surprised. We accept that when we walk into a hospital, we give up being people and become patients. We stop receiving care, the way I did on the bike path. Instead, we receive services. And when you are in pain, the difference between care and services is stark.

People in healthcare get upset when they are compared to other industries, but on this one, it’s tempting. So many companies have figured out how to do flow better. How to keep their employees engaged and sensitized and not burnt out. But in healthcare, we underinvest in that. Companies spend vast amount of time studying flow and thinking about how to ensure that customers get the services they need quickly. In healthcare, it’s considered a luxury and most organizations do very little.

Part of the reason our acceptance of mediocrity is particularly frustrating is that this is what care looks like in the most expensive system in the world. If we, as a society, chronically under-funded healthcare services, one could understand the lousy service we often provide our patients. I could live with being parked in the x-ray waiting area, ignored — if I knew that we were instead spending precious societal resources on education and research and building roads and bridges. But that’s not our story. We spend an enormous amount of money, and accept mediocre service in return.

Now that we are measuring patient experience and ER wait times as quality measures, I wondered how Falmouth hospital did. Out of curiosity, I looked up its ratings. They are fine. Average. This is not an outlier hospital. My experience was not an outlier experience. And that is the biggest disappointment of all.